Laserfiche WebLink
a � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DMSION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New / Change Edit (PROW revised 5/23/94 <br /> FACILITY ID # F 60 / a3 FACILITY NAME C.,41.—,( <br /> RECORD ID # �2 /n O� '{ PRIOR DIST # •/ PRIOR SWEEPS # <br /> (f v I I I3 SG.a� <br /> Site Mitigation: nvironmental Assessment T/CAP cal Razardous Waste Invest zMat Pipeline Invest <br /> Cher Lead Agency Site ency: IRWOC3 <br /> DISC EPA PL Site -ter Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # 6 Z I 1 PROGRAM ELEMENT # a q5 CURRENT STATUS <br /> NUMBER OF UNITS : EPA ID #: + INSPECTION CODE <br /> Number of TANK1' linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: I. the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS-EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> the Masterfile Record Information Form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date' <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, wban applicable, I, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 461.oo 461 0o w zn�o� H �g <br />